NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
NR 603 Advanced Clinical Diagnosis and Practice
Across the Lifespan
Week 2 Case Study Discussions: Pulmonary Parts One
and Two
Comprehensive 120-Question Examination - Latest Complete Solution
Chamberlain University MSN Program | Advanced Practice Nursing Curriculum
Aligned with GINA 2026, GOLD 2026, ATS/ERS, IDSA/ATS, and ACCP Evidence-Based Guidelines
Cognitive Distribution: 30% Recall | 50% Application | 20% Analysis | Question Style: 80%
Scenario-Based, 20% Direct Recall
EXAM OVERVIEW. This comprehensive 120-question examination covers the pulmonary case study discussions
from NR 603 Week 2, Parts One and Two. The exam is organized into eight sections reflecting the progressive clinical
reasoning required of advanced practice nurses at the MSN/DNP level: (1) comprehensive pulmonary history and
physical examination, (2) obstructive pulmonary disorders including asthma, COPD, and bronchiectasis; (3) infectious
and restrictive disorders including pneumonia, tuberculosis, and interstitial lung disease; (4) pulmonary vascular and
pleural disorders; (5) diagnostic testing interpretation; (6) pharmacological management; (7) Part One case study
application; and (8) Part Two complex case progression. Each question includes four response options (A-D) with one
correct answer, followed by an evidence-based rationale integrating pathophysiology, diagnostic interpretation,
pharmacology, clinical guidelines, and advanced practice nursing reasoning. Questions reflect Chamberlain University
graduate nursing case discussion format and current evidence-based practice standards (GINA 2026, GOLD 2026,
ATS/ERS, IDSA/ATS 2019, ACCP).
Section Topic Question Range
1 Pulmonary Assessment & Diagnostic Reasoning Q1 - Q16
2 Obstructive Pulmonary Disorders (Asthma, COPD, Bronchiectasis) Q17 - Q32
3 Infectious & Restrictive Pulmonary Disorders Q33 - Q47
4 Pulmonary Vascular & Pleural Disorders Q48 - Q61
5 Diagnostic Testing & Interpretation Q62 - Q76
6 Pharmacological Management Q77 - Q91
7 Part One Case Study Application Q92 - Q104
8 Part Two Case Study Application Q105 - Q120
Chamberlain University MSN Program | Advanced Practice Nursing Page 1
,NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
Section 1: Pulmonary Assessment and Diagnostic Reasoning (History, Physical
Exam, & Clinical Presentation)
Questions 1-16
Q1: A 68-year-old male presents with chronic productive cough persisting for three months. When taking
the history using the OLDCARTS mnemonic, which element is most critical for characterizing the cough
and narrowing the differential diagnosis?
A. Onset only, focusing on the exact date of symptom initiation
B. Timing and modifying factors, including diurnal variation, positional changes, and response to
bronchodilators [CORRECT]
C. Region, since cough is non-localizing and this element is irrelevant
D. Treatment response limited to over-the-counter cough suppressants
Correct Answer: B
Rationale: Timing and modifying factors are essential for pulmonary history because positional changes (e.g., worse when
supine in heart failure or reflux), diurnal variation (nocturnal worsening in asthma/CHF), and response to bronchodilators
(suggesting bronchospasm) directly shape the differential. Onset alone is insufficient, region is non-localizing for cough but
relevant for chest pain, and OTC-only treatment history omits prescribed controller medications that often drive clinical
patterns.
Q2: A 24-year-old female with a history of intermittent wheezing presents with episodic dyspnea and chest
tightness. Which HPI element is most diagnostic for asthma versus other causes of dyspnea?
A. Pain characteristics rated on a 0-10 numeric scale
B. Triggers (allergens, exercise, cold air), temporal pattern, and nocturnal symptoms waking the patient
from sleep [CORRECT]
C. Recent traumatic musculoskeletal injury to the chest wall
D. Family history of lung cancer in a second-degree relative
Correct Answer: B
Rationale: Asthma is characterized by specific triggers (allergens, exercise, cold air, irritants), variable airflow obstruction
with a temporal pattern, and nocturnal symptoms (especially between 2 a.m. and 6 a.m.) due to circadian variations in
endogenous cortisol and airway caliber. Pain characteristics are not typically relevant to asthma unless considering
complications like pneumothorax. Trauma and family history of cancer do not support an asthma diagnosis.
Q3: Which element of the past medical history (PMH) is most relevant when evaluating a 55-year-old for
possible COPD?
A. Long-standing essential hypertension managed with amlodipine
B. Childhood asthma, recurrent respiratory infections, prematurity with bronchopulmonary dysplasia,
and prior thoracic radiation [CORRECT]
C. Type 2 diabetes mellitus controlled with metformin
D. Osteoarthritis of the knees managed with PRN acetaminophen
Correct Answer: B
Rationale: Childhood asthma, recurrent respiratory infections affecting lung development, prematurity complicated by
bronchopulmonary dysplasia, and prior thoracic radiation all impair lung growth or parenchymal integrity, increasing COPD
risk. Hypertension, type 2 diabetes, and osteoarthritis are common comorbidities but do not directly modify COPD risk or
pathophysiology at the same magnitude.
Chamberlain University MSN Program | Advanced Practice Nursing Page 2
,NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
Q4: A 45-year-old male non-smoker presents with basal-predominant emphysema and mild transaminitis.
Which family history element is most concerning and should prompt further serologic evaluation?
A. Maternal asthma and allergic rhinitis
B. Alpha-1 antitrypsin deficiency (AATD) in a first-degree relative, with early-onset emphysema and liver
disease [CORRECT]
C. Lung adenocarcinoma in a grandfather who was a heavy smoker
D. Pulmonary tuberculosis in a sibling treated 20 years ago
Correct Answer: B
Rationale: Basal-predominant emphysema in a non-smoker with liver involvement is the classic phenotype of AATD, an
autosomal codominant disorder. Family history of early-onset emphysema and liver disease in a first-degree relative strongly
suggests inheritance and warrants serum AAT level with PI* genotyping. The other options reflect common conditions but do
not align with this patient's panacinar, basal emphysema pattern.
Q5: A 62-year-old female has smoked 1.5 packs of cigarettes per day for 30 years. Calculate her pack-year
smoking history, the standard metric used for COPD risk stratification.
A. 15 pack-years
B. 30 pack-years
C. 45 pack-years [CORRECT]
D. 60 pack-years
Correct Answer: C
Rationale: Pack-years are calculated as packs per day multiplied by years smoked: 1.5 x 30 = 45 pack-years. A smoking
history of 20 or more pack-years is a critical threshold that significantly raises COPD risk and qualifies for lung cancer
screening with low-dose CT per USPSTF criteria. The other options reflect miscalculations of multiplication or unit
conversion.
Q6: A 55-year-old male has worked as a sandblaster for 20 years without respiratory protection. He now
reports progressive dyspnea and a chronic cough. Chest imaging reveals bilateral upper-lobe fibrotic
nodules with eggshell calcifications in hilar lymph nodes. Which occupational pulmonary condition is most
likely?
A. Occupational asthma from isocyanate exposure
B. Silicosis, a fibrotic parenchymal disease from crystalline silica inhalation [CORRECT]
C. Bronchiectasis from chronic infection
D. Asbestosis, which typically presents as lower-lobe fibrosis and pleural plaques
Correct Answer: B
Rationale: Sandblasting is a high-risk silica exposure, producing silicosis characterized by upper-lobe fibrotic nodules and
eggshell calcifications of hilar lymph nodes. Patients are also at increased risk for TB. Asbestosis causes lower-lobe
interstitial fibrosis and pleural plaques, while occupational asthma produces reversible obstruction. Bronchiectasis presents
with chronic productive cough and airway dilation on imaging.
Chamberlain University MSN Program | Advanced Practice Nursing Page 3
, NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
Q7: On inspection of a 65-year-old male with severe COPD, you note a barrel chest, accessory muscle use,
and pursed-lip breathing. What physiologic benefit does pursed-lip breathing primarily achieve?
A. Decreases work of breathing solely by slowing the respiratory rate
B. Generates positive end-expiratory pressure (PEEP) that splints small airways open, reducing air
trapping and improving CO2 elimination [CORRECT]
C. Improves mucociliary clearance through vibratory airflow
D. Increases peak inspiratory flow to overcome fixed upper airway obstruction
Correct Answer: B
Rationale: Pursed-lip breathing creates expiratory resistance that raises intra-airway pressure, splinting collapsed small
airways open and reducing dynamic air trapping. This improves ventilation-perfusion matching and CO2 elimination. It does
not primarily act by slowing rate, enhancing mucociliary clearance, or increasing inspiratory flow, which are physiologically
unrelated mechanisms.
Q8: When assessing tactile fremitus by palpation in a 70-year-old with cough and fever, you note increased
fremitus over the right lower lobe. This finding is most characteristic of:
A. Large pneumothorax separating lung from chest wall
B. Pleural effusion creating a fluid barrier between lung and parenchyma
C. Alveolar consolidation (e.g., lobar pneumonia) increasing sound transmission through solid tissue
[CORRECT]
D. COPD with marked hyperinflation increasing air-filled parenchyma
Correct Answer: C
Rationale: Tactile fremitus increases when sound transmission improves through solid, fluid-filled, or consolidated tissue, as
in lobar pneumonia. Pneumothorax, large pleural effusion, and hyperinflation all create air- or fluid-filled barriers that
attenuate vibration, producing decreased fremitus. This principle reflects the same physics behind dullness vs hyperresonance
on percussion.
Q9: Percussion of the chest in a 60-year-old with right-sided pleuritic chest pain and dyspnea reveals a
stony dull note over the right lower lobe. This finding is most consistent with:
A. Large pneumothorax
B. A significant pleural effusion or large consolidation above the effusion [CORRECT]
C. An acute asthma exacerbation with bronchospasm
D. Emphysema with parenchymal destruction
Correct Answer: B
Rationale: Stony dullness on percussion indicates fluid or dense consolidation in the underlying tissue, most commonly a
pleural effusion (transudate or exudate) but also lobar consolidation. Pneumothorax and emphysema produce hyperresonance
due to excess air; asthma typically yields normal or hyperresonant percussion with prolonged expiration. The finding must
always be correlated with auscultation and imaging.
Chamberlain University MSN Program | Advanced Practice Nursing Page 4
NR 603 Advanced Clinical Diagnosis and Practice
Across the Lifespan
Week 2 Case Study Discussions: Pulmonary Parts One
and Two
Comprehensive 120-Question Examination - Latest Complete Solution
Chamberlain University MSN Program | Advanced Practice Nursing Curriculum
Aligned with GINA 2026, GOLD 2026, ATS/ERS, IDSA/ATS, and ACCP Evidence-Based Guidelines
Cognitive Distribution: 30% Recall | 50% Application | 20% Analysis | Question Style: 80%
Scenario-Based, 20% Direct Recall
EXAM OVERVIEW. This comprehensive 120-question examination covers the pulmonary case study discussions
from NR 603 Week 2, Parts One and Two. The exam is organized into eight sections reflecting the progressive clinical
reasoning required of advanced practice nurses at the MSN/DNP level: (1) comprehensive pulmonary history and
physical examination, (2) obstructive pulmonary disorders including asthma, COPD, and bronchiectasis; (3) infectious
and restrictive disorders including pneumonia, tuberculosis, and interstitial lung disease; (4) pulmonary vascular and
pleural disorders; (5) diagnostic testing interpretation; (6) pharmacological management; (7) Part One case study
application; and (8) Part Two complex case progression. Each question includes four response options (A-D) with one
correct answer, followed by an evidence-based rationale integrating pathophysiology, diagnostic interpretation,
pharmacology, clinical guidelines, and advanced practice nursing reasoning. Questions reflect Chamberlain University
graduate nursing case discussion format and current evidence-based practice standards (GINA 2026, GOLD 2026,
ATS/ERS, IDSA/ATS 2019, ACCP).
Section Topic Question Range
1 Pulmonary Assessment & Diagnostic Reasoning Q1 - Q16
2 Obstructive Pulmonary Disorders (Asthma, COPD, Bronchiectasis) Q17 - Q32
3 Infectious & Restrictive Pulmonary Disorders Q33 - Q47
4 Pulmonary Vascular & Pleural Disorders Q48 - Q61
5 Diagnostic Testing & Interpretation Q62 - Q76
6 Pharmacological Management Q77 - Q91
7 Part One Case Study Application Q92 - Q104
8 Part Two Case Study Application Q105 - Q120
Chamberlain University MSN Program | Advanced Practice Nursing Page 1
,NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
Section 1: Pulmonary Assessment and Diagnostic Reasoning (History, Physical
Exam, & Clinical Presentation)
Questions 1-16
Q1: A 68-year-old male presents with chronic productive cough persisting for three months. When taking
the history using the OLDCARTS mnemonic, which element is most critical for characterizing the cough
and narrowing the differential diagnosis?
A. Onset only, focusing on the exact date of symptom initiation
B. Timing and modifying factors, including diurnal variation, positional changes, and response to
bronchodilators [CORRECT]
C. Region, since cough is non-localizing and this element is irrelevant
D. Treatment response limited to over-the-counter cough suppressants
Correct Answer: B
Rationale: Timing and modifying factors are essential for pulmonary history because positional changes (e.g., worse when
supine in heart failure or reflux), diurnal variation (nocturnal worsening in asthma/CHF), and response to bronchodilators
(suggesting bronchospasm) directly shape the differential. Onset alone is insufficient, region is non-localizing for cough but
relevant for chest pain, and OTC-only treatment history omits prescribed controller medications that often drive clinical
patterns.
Q2: A 24-year-old female with a history of intermittent wheezing presents with episodic dyspnea and chest
tightness. Which HPI element is most diagnostic for asthma versus other causes of dyspnea?
A. Pain characteristics rated on a 0-10 numeric scale
B. Triggers (allergens, exercise, cold air), temporal pattern, and nocturnal symptoms waking the patient
from sleep [CORRECT]
C. Recent traumatic musculoskeletal injury to the chest wall
D. Family history of lung cancer in a second-degree relative
Correct Answer: B
Rationale: Asthma is characterized by specific triggers (allergens, exercise, cold air, irritants), variable airflow obstruction
with a temporal pattern, and nocturnal symptoms (especially between 2 a.m. and 6 a.m.) due to circadian variations in
endogenous cortisol and airway caliber. Pain characteristics are not typically relevant to asthma unless considering
complications like pneumothorax. Trauma and family history of cancer do not support an asthma diagnosis.
Q3: Which element of the past medical history (PMH) is most relevant when evaluating a 55-year-old for
possible COPD?
A. Long-standing essential hypertension managed with amlodipine
B. Childhood asthma, recurrent respiratory infections, prematurity with bronchopulmonary dysplasia,
and prior thoracic radiation [CORRECT]
C. Type 2 diabetes mellitus controlled with metformin
D. Osteoarthritis of the knees managed with PRN acetaminophen
Correct Answer: B
Rationale: Childhood asthma, recurrent respiratory infections affecting lung development, prematurity complicated by
bronchopulmonary dysplasia, and prior thoracic radiation all impair lung growth or parenchymal integrity, increasing COPD
risk. Hypertension, type 2 diabetes, and osteoarthritis are common comorbidities but do not directly modify COPD risk or
pathophysiology at the same magnitude.
Chamberlain University MSN Program | Advanced Practice Nursing Page 2
,NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
Q4: A 45-year-old male non-smoker presents with basal-predominant emphysema and mild transaminitis.
Which family history element is most concerning and should prompt further serologic evaluation?
A. Maternal asthma and allergic rhinitis
B. Alpha-1 antitrypsin deficiency (AATD) in a first-degree relative, with early-onset emphysema and liver
disease [CORRECT]
C. Lung adenocarcinoma in a grandfather who was a heavy smoker
D. Pulmonary tuberculosis in a sibling treated 20 years ago
Correct Answer: B
Rationale: Basal-predominant emphysema in a non-smoker with liver involvement is the classic phenotype of AATD, an
autosomal codominant disorder. Family history of early-onset emphysema and liver disease in a first-degree relative strongly
suggests inheritance and warrants serum AAT level with PI* genotyping. The other options reflect common conditions but do
not align with this patient's panacinar, basal emphysema pattern.
Q5: A 62-year-old female has smoked 1.5 packs of cigarettes per day for 30 years. Calculate her pack-year
smoking history, the standard metric used for COPD risk stratification.
A. 15 pack-years
B. 30 pack-years
C. 45 pack-years [CORRECT]
D. 60 pack-years
Correct Answer: C
Rationale: Pack-years are calculated as packs per day multiplied by years smoked: 1.5 x 30 = 45 pack-years. A smoking
history of 20 or more pack-years is a critical threshold that significantly raises COPD risk and qualifies for lung cancer
screening with low-dose CT per USPSTF criteria. The other options reflect miscalculations of multiplication or unit
conversion.
Q6: A 55-year-old male has worked as a sandblaster for 20 years without respiratory protection. He now
reports progressive dyspnea and a chronic cough. Chest imaging reveals bilateral upper-lobe fibrotic
nodules with eggshell calcifications in hilar lymph nodes. Which occupational pulmonary condition is most
likely?
A. Occupational asthma from isocyanate exposure
B. Silicosis, a fibrotic parenchymal disease from crystalline silica inhalation [CORRECT]
C. Bronchiectasis from chronic infection
D. Asbestosis, which typically presents as lower-lobe fibrosis and pleural plaques
Correct Answer: B
Rationale: Sandblasting is a high-risk silica exposure, producing silicosis characterized by upper-lobe fibrotic nodules and
eggshell calcifications of hilar lymph nodes. Patients are also at increased risk for TB. Asbestosis causes lower-lobe
interstitial fibrosis and pleural plaques, while occupational asthma produces reversible obstruction. Bronchiectasis presents
with chronic productive cough and airway dilation on imaging.
Chamberlain University MSN Program | Advanced Practice Nursing Page 3
, NR 603 | Week 2 Parts One & Two | Pulmonary Case Study Discussions Comprehensive Exam
Q7: On inspection of a 65-year-old male with severe COPD, you note a barrel chest, accessory muscle use,
and pursed-lip breathing. What physiologic benefit does pursed-lip breathing primarily achieve?
A. Decreases work of breathing solely by slowing the respiratory rate
B. Generates positive end-expiratory pressure (PEEP) that splints small airways open, reducing air
trapping and improving CO2 elimination [CORRECT]
C. Improves mucociliary clearance through vibratory airflow
D. Increases peak inspiratory flow to overcome fixed upper airway obstruction
Correct Answer: B
Rationale: Pursed-lip breathing creates expiratory resistance that raises intra-airway pressure, splinting collapsed small
airways open and reducing dynamic air trapping. This improves ventilation-perfusion matching and CO2 elimination. It does
not primarily act by slowing rate, enhancing mucociliary clearance, or increasing inspiratory flow, which are physiologically
unrelated mechanisms.
Q8: When assessing tactile fremitus by palpation in a 70-year-old with cough and fever, you note increased
fremitus over the right lower lobe. This finding is most characteristic of:
A. Large pneumothorax separating lung from chest wall
B. Pleural effusion creating a fluid barrier between lung and parenchyma
C. Alveolar consolidation (e.g., lobar pneumonia) increasing sound transmission through solid tissue
[CORRECT]
D. COPD with marked hyperinflation increasing air-filled parenchyma
Correct Answer: C
Rationale: Tactile fremitus increases when sound transmission improves through solid, fluid-filled, or consolidated tissue, as
in lobar pneumonia. Pneumothorax, large pleural effusion, and hyperinflation all create air- or fluid-filled barriers that
attenuate vibration, producing decreased fremitus. This principle reflects the same physics behind dullness vs hyperresonance
on percussion.
Q9: Percussion of the chest in a 60-year-old with right-sided pleuritic chest pain and dyspnea reveals a
stony dull note over the right lower lobe. This finding is most consistent with:
A. Large pneumothorax
B. A significant pleural effusion or large consolidation above the effusion [CORRECT]
C. An acute asthma exacerbation with bronchospasm
D. Emphysema with parenchymal destruction
Correct Answer: B
Rationale: Stony dullness on percussion indicates fluid or dense consolidation in the underlying tissue, most commonly a
pleural effusion (transudate or exudate) but also lobar consolidation. Pneumothorax and emphysema produce hyperresonance
due to excess air; asthma typically yields normal or hyperresonant percussion with prolonged expiration. The finding must
always be correlated with auscultation and imaging.
Chamberlain University MSN Program | Advanced Practice Nursing Page 4
